24715APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILDING-RLRCTRICAI.
BUILDING DIVISION APPLICATION/PERMIT - PLUMB IING-MECHANICAL
BUILDING PROJRCIDENTIFICATION ".
PERMIT NO.
24715 A 2 � C
4'1'
L J
BUILDING ADDRESS:
SANI'PARY NO.
APPLICATIONSUBMUTALDATE
22432 Balustral Ct. UNIT# I.OT#
`L�
OWNERS NAME: PHONE:
CONTRACT' OR NAME LIC NO:
N/C
❑
CONTROL#
' ARCALIAg
ADDRESS:
CONTACT: - PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed underprovisionsofChapter9(eommencingwith
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section 7") of Division 3 of the Business and Professions Cade, and my license is in
full to. and effect.
Licca Class Lic.# 3A63y1
'tDwe ConhadOr
L CHITECTS DECLARATION
I understand my plans shall be used as public recumb.
PANELS
UPTO 200 AMPS
201 - 1000 AMPS
OVER 1000 AMPS
SQ, ITT, FLOOR AS
$/SQ.IT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUUDMISC.
OWNER -BUILDER DECLARATION
I hereby affirm that I ma erupt from the Contrnnnr's License Low for the
TEMP. METER OR POLE INYT.
POWER DEVICES
yx'
n fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county
j which requires a Pem,it to construct, alter, improve, demolish, or repair any structure
prior its issuance, also mutinies the applicant forsuch permit no file a signed statement
sj that he is licensed pursuanno llorTmemons of The Contractors License [.me (Chapter
p R y
LE ® \V�
4 9 peommencing with Section 7000) of Division 3 ofthe Business and Pmfessimecode)
or that he is exempnhmbom andthe basis for the alleged exemption. Any violmion of
^ Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
jnotmme than five hundred dollars ($500).
prnpergorm en ewwithwa wages cam
o ❑ I,asownerofthe t yemp y g pensadon,
will do the work, nod the strunure is not intended or offered for sale (Sec. ]014. Business
SWIMMING POOL L'LECIRIC
TION
Aq bad
U E. T PECONSTRUCHON
OUTI.lil'S-SWITCHES-FlRNRES
NEW RESIDENTIAL P.LECTR S .FT.
Q
and Professions Cache; The Commeters License Law does not apply to an owner of
propcny whobuildsorimprovesthemon, sadwhodoessuch work himxlfor through his
ownanployucs, provided that such hamovementsurenot Intended oroffemd forsale.If,
OCC, GROUP RES. UNITS
however, the building or improvement is sold within one yearofcnmpletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
TOTAL:
QTY. PLUMBING PERMIT ,PEE'
sale.).
❑ T, as owner ofthe proceny,am exdusivelyconvacting with licensedcmmmcmreto
FLOOD ZONE APN
construct the project (Sec. 70,00, Business and Professions Cade:) The Contractor's
License Law does not apply taunownerofproperty whobuildsor improves thereon, and
PERMIT ISSUANCE
whoconamets fosuch projects withacontrectur(s) licensed pursuanno Ne Contreemer
License taw.
��:R-DRAIN&VENT-WATCR EA
( )
FEE SUMMARY,-
❑ I um exempt under Sec. , B & PC for this reason
BACK PLOW PROTECT DI?V ICE
O T. ID , FEES
SANITARY Y
Owner Date
DRAINS- FLOOR, ROOF. AREA, COND.
_N
RECEIPT #
WORKMAN COMPENSATION DECLARATION
❑ Thereby affirm thetlhave aceniGcate ofconsennosel4insom, oracenificute of
Worken'Compensmlon lnsamnceoraeenl0ul copy thawf(Sem.3g00, Loh C.)which
Policy Nll employees under this permit. 17010
SCHOOLTAX Y N
RF.CEIPT0
FIXTURES - PER'TRAP
PARK FEE V Ncovers _
RF.CHII'f M
GAS - HA. SYSTEM-] INC. 4 OUTLETS
BUILDING DIVISION HIS
Coming
GAS - EA. SYSTEM OVER 4 (EAU
PLANCHECK HE
❑ m
Ccopy is e
[X Cenffied copy is filed with the city inspection division.
GREASIVINDUSTItL WASTE INTERCEPTOR
GRADING PHI?
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRGSETILAP
SOILS FEE
(This section need not he completed ifthe Permit is for one hundred dollars ($100)
or less.)
SEWER - SANITARY - STORM F.A. 201
ENERGY FETE
WATER HEATER WNENT/F.I.ECTR
I certify that in the performance ofthe work for which this permit is issued, )shall
not employ any Person in say momter so as m become subJect m the Workers'
Comcenmtion Lawsof Califomia. Date
Applicant
WATER SYSTEMOREATING
PAID
Date Receipt#
NOTICE TO APPLICANT: If, alter making this Cenificato of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. PI''
TOTAL:
forthwith comply with such provisions or this permit shall be deemed accused.
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there is a construction lending agency for doe performance of
TOTAL:
ELECTRIC THIS
the work for which this permit is issued( Sec. 3097, Civ. C.)
Lenders Name
Landers Address
QTY. MECHANICALPERMIT " FEE -
PLUMBING FEE
1 certify that 1 have read this application and state that the above information is
1 PERMITISSUANCE
ALTL'R OR ADD TO MECH.
MECHANICAL HE
cored. l agree to comply with all city and county ordinances and state laws rchougm
building construction, and hereby aathonic representatives of Nis city to enter upon the
above-mentioned proceny for inspection puryoses.
CONSTRUCTION TAX
(We) name to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way permit against said City
AIR HANDLING UNIT (TO 10,000 CFM)
in consequence of the grunting .1 this permit.
AIR HANDLING UNIT (OVER 10,0(() CFM)
11 94
�/
Signature of ApplicanUCommanr Date
EXHAUST HOOD (W/DUCT)
PAID
HEAPING UNIT (TO 100,000 B' N)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will the applicant or future building occupant store or hatdle haverdous mmenal
as defined by tM Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
/ HEATING UNIT (OVER 100,1300 BTU)
TOTAL:
Code, Section 25532(x)?
VENTILATION FAN (SINGLE RISID)
�#
❑Yes $1 No
Will theaconacraiorfurore building occupantase equipment
BOILER - COMP L IHP OR 100,000 BTU)
ISSUANCE DATE
hartrict? air contaminants as defined by the Pay Arco Air Quality Menngement
Quality Management
District?
Dismct? y All
❑ Vas QN
y1
P' r
BOILER - COMP (OVER Ho,008 BTU)
NEW RESIDENTIAL MECH. SQ, FT.
I have read the hazvdous matmiak requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand Nat
NOV - 31993
if the building does not carently have a tenant, that it is my responsibility in notifyIbe
"Cannot of the requirements which must be met prior to issuance of a Certificate of
ocupancy. 11/2/93
_
.a CI77 VF.M W
ISSUED BY: _.\.Jv
Owner or amhonttd agent hate
TOTAL:
OFFICE �i